Decompression with lumbar facet arthroplasty associated with superior outcomes vs. fusion
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Key takeaways:
- Lumbar facet arthroplasty was associated with superior outcomes vs. spinal fusion for stenosis and spondylolisthesis.
- Overall, 73.5% of patients in the facet arthroplasty group achieved clinical success.
According to published results, decompression with lumbar facet arthroplasty was associated with superior clinical outcomes vs. decompression with fusion for patients with spinal stenosis and spondylolisthesis.
Researchers randomly assigned patients with lumbar spinal stenosis and grade 1 degenerative spondylolisthesis to undergo decompression with either lumbar facet arthroplasty (n = 219) or spinal fusion (n = 102).
Outcomes were assessed at 2-year follow-up and included composite clinical success scores, Oswestry Disability Index (ODI), VAS back and leg pain scores, the Zurich Claudication questionnaire and the SF-12 questionnaire.
Overall, 113 patients (51.6%) in the facet arthroplasty group and 47 patients (46.1%) in the fusion group had complete composite clinical success scores. Researchers noted eight patients in the facet arthroplasty group and four patients in the fusion group were excluded due to early clinical failure. However, data from these patients were still included in the composite clinical success analysis.
Researchers found 73.5% of patients in the facet arthroplasty group achieved composite clinical success compared with 25.5% in the fusion group. Researchers also noted the facet arthroplasty group had greater improvements in ODI, VAS and Zurich Claudication questionnaire scores at 2 years compared with the fusion group.
Researchers concluded the higher composite clinical success scores in the facet arthroplasty group were “driven by higher rates of fusion failure, new or progressive neurologic deficit and failure to achieve sufficient reduction in low back disability (as measured by the ODI) in the fusion group.”
Perspective
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The authors present results of a prospective, randomized, non-blinded trial of lumbar decompression with a facet arthroplasty device compared against transforaminal lumbar interbody fusion in patients with degenerative spondylolisthesis and neurogenic claudication. A motion-sparing alternative to fusion would be desirable in these patients. The study design is good, and the patients seem to be well randomized.
Although the results offer promise for the arthroplasty device in this patient group, there are several aspects of the study that could temper the reliability of the conclusions. First, less than half of the patients had 2-year follow-up, and that is below the desirable rate for a clinical trial to be considered level I evidence. Secondly, the nonunion rate of 44%, which led to the high percentage of failure in the fusion group, is exceedingly high, especially for a single-level transforaminal lumbar interbody fusion, where most modern studies would suggest a nonunion rate below 10%. In addition, only plain radiographs were used to assess fusion status, rather than CT scans, which makes the fusion assessment much less reliable. Finally, other studies of patients with degenerative spondylolisthesis have shown that the 5-year follow-up is a more critical time point, compared with 2 years in patients not receiving a fusion, and it is unclear whether the pedicle screws that affix the arthroplasty device may loosen over time and allow increased motion beyond what this constrained device would permit. In addition to a more accurate determination of fusion status in the fusion group, CT scans would afford determination of long-term screw fixation in the arthroplasty group, which could be a concern in a patient population that is often osteopenic.
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